Julie T. Steck, Ph.D., HSPP
CRG/Children’s Resource Group
www.childrensresourcegroup.com
Calli is an 8-year-year old female, currently in grade 2
Initially seen for fears of getting sick and vomiting
Frequent headaches and stomachaches on school days
Has emotional meltdowns at home
Well-behaved at school but gets little work done
Homework time results in arguments
Makes friends easily but does not sustain friendships
Gravitates to playing with boys and/or girls who are active and impulsive
Sucks her thumb when watching videos
Has difficulty falling asleep at night
Needs much prompting to get ready for school or bed
“Lies” about little things
Talks constantly
Does not entertain herself well
38-year-old female whose son had been diagnosed with ADHD
Mother of two children, remains at home
Diagnosed and treated for anxiety and depression for years
Graduated from college but always thought of herself as “dumb”
Overweight and reported that she is always dieting
Struggles with completing daily tasks such as cleaning and shopping
Very social but has a hard time saying “no”
Procrastinates and then feels stressed
Stays up late at night and can get “lost” on the internet
Struggles with waking up in the morning
Feels that she is constantly disappointing others by not completing what she expects of herself
Mood disorders
Eating disorders (primarily bulimia)
Anxiety disorders
Substance abuse
Cigarette smoking
Academic underachievement
Poor self-esteem
Suicidal thinking and self-injurious behaviors
Recognize the symptoms of ADHD in females across the lifespan
List four long-term consequences of untreated ADHD in females
Identify the other mental health conditions which often co-exist with ADHD in females
List four essential components of a treatment plan for females with ADHD
ADHD is underdiagnosed—estimates are that 9% of children and adolescents have ADHD
Only 50% of those with ADHD are diagnosed
ADHD is undertreated—only 40% of those with ADHD have been treated and treatment is often discontinued
A developmental disorder
Diagnosed relative to an age group(more difficulty than 7-10% of peers)
Results in 30% in acquisition of self-regulation and self-control
Persists throughout lifespan in at least 60%--more likely up to 90%
Not an input disorder
A disorder of performance, not skill
Not a matter of not knowing what to do
But doing what you know when you need to do it
Responding more to stimuli than others do
Poor persistence of responding
Impaired resistance to distraction
Deficient task re-engagement following a disruption
Impaired motor inhibition
Poor sustained inhibition
Excessive and often off-task motor and verbal behavior
External restlessness becomes internal with age
I am often easily distracted by extraneous stimuli.
I often makes decisions impulsively.
I often have difficulty stopping activities or behavior when I should do so.
I often start a project or task without reading or listening to directions carefully.
I often show poor follow through on promises or commitments I may make to others.
I often have trouble doing things in their proper order or sequence.
I am often more likely to drive a motor vehicle much faster than others.
I often have difficulty sustaining attention in tasks or play/recreation activities.
I often have difficulty organizing tasks and activities.
Cutoff=4 of first 7 or 6 of all 9 symptomsFrom Barkley, Murphy and Fischer (2008)
Russell Barkley, Ph.D.
CHADD Conference 2006
Education
Occupation
Social
Community/legal
Dating/marital
Driving
Leisure
Daily Responsibilities
Financial
Reduced productivity is biggest problem
High school drop out rate 30-40% higher
Grade retentions increase 35-45%
Suspensions increase 40-60%
Expulsions increase 10-18%
Fewer enter college (22% vs. 77%)
Lower college graduation
(5-10% vs. 35%)
Lower GPA (1.8 vs. 2.4)
Taken from Barkley & Gordon, 2002
Enter workforce at unskilled/semi-skilled level
Unemployment (22% vs. 7%)
More likely to be fired (55% vs. 23%)
Change jobs more often
Lower work performance ratings
Greater use of sick days
Greater use of health insurance claims
By 30’s 35% are self-employed
Fewer close friends
Shorter duration of relationships
Spend more time watching TV, talking on phone, socializing
Spend less time reading, studying, and exercising
Greater parenting stress and maternal depression
Less sharing, turn-taking, and cooperation in children
More conflict with siblings
Increased emotional responses
Can be intrusive with others
2.5 times as likely to die by accident or suicide
Increased rate of cigarette smoking and earlier age of starting
Significantly higher rate of Substance Use Disorder
Poorer steering and slower braking reaction time
More likely to drive before licensed
More accidents (2-3 x increase)
4 times the number of speeding tickets
Worse accidents (cost 2 ½ x more)
Impact on alcohol on driving is worse
Begin sexual activity earlier (15 vs. 16)
More lifetime sexual partners (13.6 vs. 5.4)
More partners in prior year (2.4 vs 1.6)
Less time with each partner
Less likely to use contraception
Higher rate of teen pregnancy (38% v. 4%)
Higher risk for STD’s (17% vs. 4%)
No higher risk of sexual disorders
Higher rate of divorce and marital discord
The most researched childhood condition with studies looking at the implications on adult psychopathology
Not well studied in females
Linked to long-term negative outcomes in males
Linked to significant deficits in executive function
Highly genetic
More premature babies survive
More recognized
Increased demands of education and society cause increased “functional impairment”
Multiple genes are involved
If one parent has AD/HD, each child has 30% risk of having AD/HD
If both parents have AD/HD, each child has more than 50% risk
If one child has AD/HD, 30% chance that each sibling has it
Baseline study involved 140 females age 6-17 years of age and 122 girls without ADHD
Exclusionary factors: adoption, sensorimotor impairments, psychosis, autism, limited English language proficiency, IQ below 80
11-year follow-up included 96 females with ADHD and 91 without ADHD
Follow-up procedures included:
Structured Clinical Interview for DSM-IV (SCID)
When appropriate Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiological Version (K-SADS-E)
At follow-up the group analyzed:
Had a mean age at follow-up of 22
Was primarily Caucasian
Had primarily intact families
62% still had impairing symptoms of ADHD
Significantly greater risks of antisocial, mood and anxiety disorders
Lower risk of antisocial personality disorders compared to males with ADHD
Higher rates of major depressive and anxiety disorders compared to males with ADHD
High rate of agoraphobia (25%) and social phobia (20%)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
MDD BIPOLAR ANXIETY BULIMIA
COMPARISON ADHD
Baseline study included 140 females with a combination of ADHD-Combined (93) and Inattentive (47) and 88 in comparison group
Common comorbidities were not excluded
Sample was ethnically diverse and there was a range of income levels
Follow-up study included 105 with ADHD and 86 in comparison group
Follow-up measures included DISC-IV, SNAP-IV, ABCL, ASR, BDI, SUQ, EDI, WIAT-2, and others
Those with childhood-onset ADHD showed greater symptoms of psychopathology and had larger functional impairments
In most domains, those with ADHD Combined and Inattentive showed little difference
Those with ADHD-Combined showed higher rates of suicide attempts (22.4%) and self-injury (50.6%)
Most consistent findings were from parent-report and objective measures-not self-report
Academic impairment in math
0%
10%
20%
30%
40%
50%
60%
DISC-IV CD/ODD DEPRESSION/DYSTHYMIA ANXIETY
Chart Title
COMPARISON GROUP INATTENTIVE COMBINED
From a public health perspective, the
ability to predict the outcome of
ADHD in girls would help focus
limited resources on those individuals
who are at higher risk for persistent
illness with complicated outcomes.”
Biederman, J. et al. Adult Psychiatric Outcomes of
Girls with Attention Deficit Hyperactivity Disorder:
11-Year Follow-Up in a Longitudinal Case-Control
Study. American Journal of Psychiatry 2010; 167:
409-417.
I often want to cry. (yes/no)
I get a lot of stomachaches or headaches. (yes/no)
I worry a lot. (yes/no)
I feel sad, and sometimes I don’t even know why.
(yes/no)
I dread being called on by the teacher because, often, I haven’t been listening carefully. (frequently/rarely)
I feel embarrassed in class when I don’t know what the teacher told us to do. (frequently/rarely)
Even when I have something to say, I don’t raise my hand and volunteer in class. (yes/no)
Sometimes, other girls don’t like me, and I don’t know why. (yes/no)
I have arguments with my friends. (often/rarely)
When I want to join a group of girls, I don’t know how to approach them, or what to say.
(frequently/rarely)
I often feel left out. (yes/no)
I get my feelings hurt more than most girls do.
(yes/no)
My feelings change a lot. (yes/no)
I get upset and angry more than other girls. (yes/no)
Diagnosis of ADHD should not be a “yes-no” questions
Diagnosis should start with the question of what is the nature of the person’s difficulties
Diagnosis should include consideration of the comorbid conditions
ADHD is not an excuse—it is an explanation
ADHD helps explain why behaviors are repetitive and do not quickly change
A diagnosis of ADHD helps those who are close to the individual recognize that the behaviors are not personalized
A diagnosis of ADHD helps those close to individuals with ADHD know how to support them
Diagnosis
Parent and patient education regarding ADHD
Consideration of medication
External supports, psychotherapy, and ADHD coaching to address ADHD and related issues
Diagnosis and treatment helps “level the playingfield”
Parental and educator understanding helps knowhow to intervene
Parental understanding helps to anticipate needs for changes in parenting with each developmental level
Awareness of the hereditary nature helps to identify others in the family who may need support
Recognizing each individual’s strengths and assets allows us to focus on those as we support their needs
Poor impulse control is usually recognized before attention problems
ADHD is not just an academic problem and many students with ADHD can do well in school until the need for organization and time management outstrip their cognitive capabilities
Those with ADHD typically have about a 30% delay in the acquisition of independent skills and social-emotional development. Thus, a 12-year-old may only be as responsible as a typical 9 year old.
For individuals with ADHD, time is the enemy. If they are doing something they enjoy, there is not enough time. If they are to do something they don’t enjoy, they will procrastinate or just not do it.
Individuals with ADHD have difficulty sustaining mental effort.
They also have trouble remembering to do what they need to do when they need to do it.
Those with ADHD live in the moment—they don’t reflect on the past to remember what happened last time or look to the future to think of the consequences of their behavior.
ADHD causes individuals to have trouble stopping a behavior in the middle of a behavior.
Most of what we know about ADHD is based on research on males but females with ADHD are just as much at risk for problems in all areas of functioning
Hope starts with diagnosis. Without diagnosis, much time, energy and money is spent on ineffective treatment. When
treatments don’t work, the blame begins.
Barkley, R.A. (1998) Attention-Deficit Hyperactivity Disorder Second Edition. New York, NY. The Guilford Press.
Barkley, R. A. & Gordon, M. (2002). Comorbidity, cognitive impairments, and adaptive functioning in adults with ADHD: Implications of research for clinical practice. In S. Goldstein & A. Teeter (Eds.), Clinical interventions for adult ADHD: A comprehensive approach (pp.46-69). New York: Academic Press.
Barkley, R., Murphy, K., & Fischer, M. (2008). ADHD in adults: What the science says. The Guilford Press.
Biederman, J., Petty, C.R., Monuteaux, M., Fired, R., Byrne, D., Mirto, T., Spencer, T., Wilens, T., & Farone, S. Adult Psychiatric Outcomes of Girls with Attention Deficit Hyperactivity Disorder: 11-Year Follow-Up in a Longitudinal Case-Control Study. American Journal of Psychiatry, 167:4, 409-417.
Hinshaw, S., Huggins, S., Montenegro-Nevado, A., Owens, E., Schrodek, E., Swanson, E., & Zalecki, C. Prospective Follow-Up of Girls with Attention-Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide and Self-Injury. Journal of Consulting and Clinical Psychology, 80:6, 1041-1051.
Nedeau, Littman, & Quinn. (1999) Understanding Girls with ADHD. Advantage Books.
www.addvance.com
http://www.apa.org/topics/adhd/index.aspx
www.chadd.org
http://www.childrensresourcegroup.com/underdiagnosed-and-misunderstood-girls-with-adhd/
http://www.childrensresourcegroup.com/toward-better-diagnosis-and-understanding-girls-with-adhd/